Risk adjustment: addressing the "how"

Kristin Rodriguez, Health Plan Alliance

04/03/2017

February 15-17 brought Alliance member health plans together
to talk about risk adjustment, which may very well be the defining issue of
success for plans operating in government-sponsored health care markets,
particularly the ACA and Medicare Advantage. Members who weren’t able to
attend the sessions in person can access podcasts of each session, as well as
copies of the presentations and materials online.

While previous value visits on this topic have focused on
the “what,” with sessions focused on educating member plans on the risk
adjustment score calculation methodology, the strategic importance of
partnering with providers, and updates on advocacy work on the 3 R’s, this
year’s event really dove deep into the “how.”

Documentation accuracy

The coding work group met
face-to-face for the first time, kicking off the Value Visit with one of the
group’s 90 minute workshops on documentation best practices. For those
member plans not yet involved in the coding work group, we hope your risk
adjustment leaders and your certified coders from both your health plan AND
your provider partner organizations will consider attending these virtual
sessions. Coders can earn CEUs and benefit from best practice sharing
with a large group of coding and documentation experts. As always, this
programming and CEU benefit is part of your membership benefits and presents no
extra cost for you or your provider partner stakeholders. The coding
workgroup is moderated by the Alliance’s Nicole Terranella. Contact her or visit
our coding workgroup home page for upcoming events and more information.

Dashboards

Enhancing documentation accuracy was just one area where the
importance of engaging providers was top of mind. As plans become more
attune to the concerns of their clinical stakeholders, dashboards are becoming
more prominent and discussion on this topic was led beautifully by Avera Health
Plan. Stay tuned in 2017: We are actively working on scheduling more
show-and-tell opportunities on provider dashboards. But working with
outside stakeholders more effectively and aligning incentives is just one piece
of a big and complicated puzzle. Ed Vozzo of Community
Health Options shared the details of their organization’s roller coaster
ride in the Exchange market, and how they are endeavoring to leverage what they
can learn from risk adjustment data more proactively in their product design
moving forward. For those eager for more details on the complicated
calculations that happen in the background throughout these decision making
processes, Wakely
Consulting walked attendees through the ways in which risk adjustment
absolutely influences product design and made suggestions on how plans can
leverage this information throughout their product lifecycle.

Structure

Strategy absolutely drives structure, and attendees
discussed in great detail how that is proving at their respective health
plans. MediGold and Pulse8 partnered for a case study on
implementing a new vendor relationship, and MediGold is presenting an
encore presentation that focuses more explicitly in their robust RFP process,
and the way in which their leadership navigated the crowded market of risk
adjustment vendors to drive toward what their plan needed from their new vendor
partner. Join
us for this health plan case study on May 3rd. Health
plans also shared details of their risk adjustment departments’ structure and
operational frameworks. Dozens of resources were submitted by member
plans – everything from organizational charts to department charters, job
descriptions, policies and procedures and templates. We hope you’ll
explore this rich resource collection by visiting the event page and reviewing
the documents
tab contents. Health First took on the final speaking spot of the
event – an often feared speaking role! – with gusto and shared their vision for
risk adjustment. Health First’s efforts in this area have long-impressed
us here at the Alliance and their case
study did not disappoint. We hope to bring their team back for an
encore presentation later in 2017 as well, so their Alliance peers can continue
learning from their innovations.

Navigating policy and regulation

In so many ways, risk adjustment requires health plans to
constantly react to an often volatile environment, with pressures from both
policymakers and regulators continually growing. A great deal of
discussion was dedicated to understanding the environment in which we find ourselves
operating, and discussing best practices in audit
readiness, managing the risk of
overpayment, and preparing for continued uncertainty from the
legislative environment. A particularly hot topic continues to be the
IVA audit process. In fact, the Alliance launched a member survey in February
and that was the topic of our round table discussion on best
practices for a smooth and effective IVA process. The session
explored members’ satisfaction with IVA vendors, and what plans are coming to
expect from these vendors as they navigate the process. The topic remains
so critical, we launched a revised survey. The updated survey results were shared during our March 31st
Risk Adjustment Roundtable Value Call.

With so many challenges ahead, Alliance members requested
more opportunities for health plan members to come together and continue the
collaboration and discussion on all things “risk adjustment.” To support
this need, the Alliance has scheduled a standing roundtable discussion and
value call on the last Friday of every month in 2017. We encourage all
stakeholders in risk adjustment from your health plan AND from your provider
partner organizations to register for these calls.